How HMO Works: Emergency Room Coverage

Do you have an HMO health plan? HMO is the acronym for Health Maintenance Organization. Your HMO coverage covers routine preventive care – along with emergency care.

Knowing you have health care coverage that you can count when an accident or unexpected health crisis strikes means you can breathe a little easier. After all, there’s never a good time to break an arm, fracture a rib or have chest pains.

A visit to the emergency room costs more than a visit to your primary care physician (PCP). That’s why it’s important to be absolutely positive you need to go to the emergency room. If you’re not sure, you call your doctor for advice. Together, you can decide if you need to go to the doctor’s office or the emergency room. For stomach aches, fevers, minor burns and other health issues, make an appointment to see your PCP.

If you believe your health issue is life-threatening, don’t wait. Call 911, or go to the nearest hospital emergency room right away. The emergency room will then reach out to us to approve your care. If you’re admitted to the hospital from the ER, you or a family member should call your PCP within 72 hours. Involving your PCP as soon as possible can help you get the post-ER care you need. Even if you aren’t admitted, you will still need to call your doctor soon after you leave the hospital to schedule follow-up care.

While emergencies happen suddenly, a little advance planning can help you when minutes count.

Be Prepared

• Know what your HMO plan covers. Your policy kit includes a summary of your costs and coverage. Find details about your plan at Blue Access for Members^SM (BAM^SM). With 24/7 access, you can review your plan’s benefits, claims, information and print a temporary member ID card.
• Know where to find your member ID card. Keep your member ID card in a place that’s easy to find at all times, like your wallet. Let someone you trust know where they can find your card in case of an emergency.
• Locate your nearest hospital emergency room or retail clinic. Use the Blue Cross and Blue Shield of Texas Provider Finder^® tool to locate your neighborhood in-network health care providers.

Know What Your HMO Plan Covers

• The most important thing to worry about in a life-threatening health crisis is getting yourself to the nearest emergency room. For some plans, the cost for a trip to an in-network emergency room and an out-of-network emergency room are about the same.
• Remember that the copay for visiting the ER is much higher than the copay for visiting your PCP. Emergency room copays can cost you hundreds of dollars. To get a clear understanding of your coverage benefits, review your policy kit, check your plan details in Blue Access for Members, or call the number on the back of your member ID card.
• In many cases, if you’re admitted to a hospital that is not in-network, your stay will not be covered. This is why, if possible, you want to contact your PCP prior to being admitted so you can be referred to a location that is in-network. If you do go to an out-of-network hospital, however, the out-of-network hospital will transfer you to an in-network hospital for ongoing inpatient care once you are well enough.

Get Answers Before You’re Admitted to the Hospital

It’s important to know that your HMO coverage for your emergency room visit ends if you’re admitted to the hospital. Remember, if you’re admitted to a hospital that is not in your network of providers, you’ll be charged the full cost of your treatment and stay. It’s important to contact your PCP if you’re being admitted so they can ensure you are referred to a facility that is in your network.

Ask these questions:

• Does this facility accept my insurance plan?
• What medical care does the facility provide?
• What practitioner is on duty now? Is there an HMO doctor or nurse?
• How much will this treatment cost?
• Are lab and other tests included in my coverage? How much will I have to pay?
• Is there a separate charge for any and all other treatments I may receive?
• Will treatment be covered by my insurance or how much will I have to pay?

There’s a lot to consider when deciding where to go for care. We’re here to help you understand all of your options.

Not all benefits are offered by all health plans. Please refer to your benefit materials or log in to Blue Access for Members to see the limitations and exclusions in your plan. If you want to verify your coverage and identify your medical group and PCP, visit the Coverage tab.

Questions? Register for Connect and ask us in the forum or send us a private message.

Disclaimer: The information provided in this document is based on current information, should not be considered comprehensive and should not be relied upon for benefit decisions. It should not be considered legal or tax advice.

Originally published 4/28/2015; Revised 2023